ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment A
1. A nurse is receiving a report on four clients. Which of the following clients should the nurse assess first?
- A. A client who has an ileal conduit and mucus in the pouch
- B. Client with arteriovenous fistula with additional vibration palpated
- C. A client with chronic kidney disease and cloudy dialysate outflow
- D. A client with transurethral resection of the prostate with red-tinged urine
Correct answer: C
Rationale: The nurse should assess the client with chronic kidney disease and cloudy dialysate outflow first because cloudy dialysate outflow suggests peritonitis, a serious complication of peritoneal dialysis that requires immediate intervention. Assessing and addressing peritonitis promptly is crucial to prevent further complications and ensure the client's safety. Choices A, B, and D present important findings that require attention but are not as urgent as peritonitis, which can quickly escalate and endanger the client's health.
2. A nurse is assessing a client with chronic kidney disease. Which of the following should the nurse monitor for?
- A. Hyperkalemia
- B. Hypercalcemia
- C. Hypoglycemia
- D. Hyponatremia
Correct answer: A
Rationale: The correct answer is A: Hyperkalemia. Clients with chronic kidney disease are at risk for hyperkalemia due to impaired potassium excretion. In chronic kidney disease, the kidneys are unable to effectively excrete potassium, leading to its accumulation in the blood. Hypercalcemia (Choice B) is not typically associated with chronic kidney disease. Hypoglycemia (Choice C) refers to low blood sugar levels and is not directly related to chronic kidney disease. Hyponatremia (Choice D) is a condition characterized by low sodium levels and is not a typical concern in chronic kidney disease.
3. A hospice nurse is providing teaching to a patient who has a new diagnosis of a terminal illness and her family. Which statement should the nurse include in the teaching?
- A. Hospice care will help provide rehabilitation for the patient.
- B. Hospice care focuses on extending life by any means necessary.
- C. Hospice care will help the patient transition to nursing care.
- D. Hospice care continues to help families with grief after a death occurs.
Correct answer: D
Rationale: The correct statement that the nurse should include in the teaching is option D: 'Hospice care continues to help families with grief after a death occurs.' Hospice care not only focuses on providing comfort care for terminal patients but also offers bereavement support to families after the patient's death. Choices A, B, and C are incorrect. Option A is incorrect because hospice care does not provide rehabilitation for the patient; its focus is on comfort and quality of life. Option B is incorrect because hospice care does not aim to extend life but rather to provide quality end-of-life care. Option C is incorrect because hospice care does not transition patients to nursing care; it provides care focused on comfort and symptom management in the patient's preferred setting.
4. A school nurse is providing care for students in an elementary education facility. What intervention by the nurse addresses the primary level of prevention?
- A. Monitor for signs of illness.
- B. Teach students about healthy food choices.
- C. Administer medication to students with chronic conditions.
- D. Monitor immunization compliance.
Correct answer: B
Rationale: The correct answer is B: Teach students about healthy food choices. Teaching healthy habits like proper nutrition is an example of primary prevention because it aims to prevent disease before it occurs. Choice A, monitoring for signs of illness, is more related to secondary prevention (early detection and treatment). Choice C, administering medication to students with chronic conditions, is a form of tertiary prevention (managing existing conditions to prevent complications). Choice D, monitoring immunization compliance, is also a form of primary prevention but focuses on preventing specific infectious diseases through immunization rather than general health promotion.
5. A nurse is caring for a client with celiac disease. Which food should be removed from the meal tray?
- A. Cornbread
- B. Mashed potatoes
- C. Lentils
- D. Tortillas
Correct answer: D
Rationale: The correct answer is D, Tortillas. Clients with celiac disease should avoid gluten, which is often found in tortillas. Cornbread, mashed potatoes, and lentils are gluten-free options, making them safe for individuals with celiac disease. Therefore, the other choices (A, B, and C) do not need to be removed from the meal tray.
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